Health plans and TPAs
Health plans are insurance policies that private companies or government programs offer to cover healthcare costs for enrolled individuals. Third-party administrators manage and process insurance claims for these health and employee benefit plans, often serving as intermediaries among healthcare providers, payers and beneficiaries.
Top Stories
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23 Apr 2026
CMS benches BALANCE Model for Medicare
The federal agency announced an indefinite delay to the Medicare Part D portion of the upcoming model that would expand coverage criteria for GLP-1s. Continue Reading
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22 Apr 2026
When brand-name drugs need a prior auth, brace for delays
A study uncovered friction at the pharmacy, revealing days-long delays and frequent denials when brand-name prescription drugs need a prior authorization. Continue Reading
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20 Feb 2020
Challenges and Solutions of Medicaid Beneficiary Communication
The diversity of preferences makes Medicaid beneficiary communication and member engagement challenging but not insurmountable. Continue Reading
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19 Feb 2020
Appeals Court Strikes Down AR Medicaid Work Requirements
The appeals court found Secretary Azar’s approval letter failed to address concerns about Medicaid work requirements. Continue Reading
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18 Feb 2020
GAO Reveals Medicaid Eligibility Inaccuracies, Recoup Strategies
Sixty-two percent of states in a GAO report had incorrect or incomplete income or asset information in their Medicaid eligibility determinations. Continue Reading
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17 Feb 2020
VA Medicaid Program Reduces ED Admissions for Opioid Use Disorder
Virginia’s Medicaid programs responded to the opioid crisis by expanding treatment for beneficiaries with opioid use disorder, reducing ER admissions by 21.1%. Continue Reading
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05 Feb 2020
HIV Patients Could Lose Coverage Under Medicaid Work Requirements
Medicaid work requirements, if scaled nationally, could mean unstable coverage or ineligibility for patients with HIV. Continue Reading
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05 Feb 2020
What are Impacts of the Medicaid Fiscal Accountability Regulation?
The Medicaid Fiscal Accountability Regulation is a proposed rule from CMS that seeks to reform provider reimbursements and control Medicaid spending. Continue Reading
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04 Feb 2020
Medicaid Expansion May Improve Minority and Low-Income Employment
Minority and low-income employment and academic status increased in Michigan for the Medicaid population while the statewide trends were fairly static. Continue Reading
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03 Feb 2020
ACA Leads to Insurance Gains, Affordable Access to Care Wanes
The ACA successfully increased insurance rates in the US, but high healthcare costs continue to dampen patients’ access to care. Continue Reading
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30 Jan 2020
How State Budgets Impact Medicaid Funding, Reveal Priorities
Budget negotiations explore Medicaid expansion, leverage Medicaid privatization, pursue cost savings, and place Medicaid funding at the mercy of politics. Continue Reading
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29 Jan 2020
Medicaid Expansion May Impact Patient Outcomes in Southern States
While southern states debate Medicaid expansion, researchers find that Medicaid expansion led to better coverage and better patient outcomes. Continue Reading
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20 Jan 2020
Medicaid Expansion Means Better Postpartum Coverage, Utilization
Colorado’s Medicaid expansion may be responsible for its superior rate of postpartum coverage and utilization when compared to Utah, which did not expand Medicaid. Continue Reading
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16 Jan 2020
2017 State Medicaid Spending Rose as Feds Withdrew Funding
State Medicaid spending from states’ own revenues increased as states took on more responsibility for their own Medicaid spending in 2017. Continue Reading
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15 Jan 2020
Cost of Cancer Care Reaches Nearly $150B Nationally
Many cancer patients struggle with out-of-pocket cancer care expenses, with one drug costing nearly $12,000 annually and FDA approved drugs priced over $100,000 a year. Continue Reading
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03 Jan 2020
Despite Early Low Enrollment, Federal Exchange Enrollment Steady
The federal exchange enrollment was around 20 percent lower than last year in an early analysis but rose to just shy of last year’s overall enrollment. Continue Reading
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26 Dec 2019
Best Practices to Address Opioid Use Disorder for Medicaid Directors
A new toolkit identifies best practices for Medicaid directors to address opioid use and substance abuse in their states. Continue Reading
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19 Nov 2019
How Patient Navigators Drive the Medicare Open Enrollment Season
Patient navigators leading Medicare open enrollment season report that the multitude of plans, regulatory changes, and new technologies confuse enrollees. Continue Reading
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27 Aug 2019
Medicare Plan Finder Aims for Price Transparency, Plan Comparison
The new CMS Medicare Plan Finder seeks to streamline price transparency and plan comparison through new features and a refreshed design. Continue Reading
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13 Aug 2019
How Health Policy is Working to Reduce Medicare Drug Spending
Policymakers have targeted Medicare drug spending from many angles to drive down healthcare costs. Continue Reading
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31 Jul 2019
Expanding Medicare Supplemental Benefits to Benefit Seniors
With fewer Medicare beneficiaries receiving supplemental coverage through employer-sponsored insurance, Medicare’s supplemental benefits should expand. Continue Reading
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24 Jul 2018
Generic Drugs Could Have Saved $3B for Medicare Part D Program
The Medicare Part D program could have saved $3 billion in 2016 if the payer encouraged generic drug substitution over the use of brand-name therapies. Continue Reading
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29 May 2018
Preventing Provider Fraud through Health IT, Data Analytics
Payers that want to improve their ability to detect and react to provider fraud must invest in health IT and data analytics solutions to flag criminal activity. Continue Reading
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07 Jun 2017
Two Payers Liable for $32.5M in Medicare Advantage Fraud Suit
Freedom Health and Optimum Healthcare have been ordered to pay $32.5 million for systemic Medicare Advantage fraud alleged by a whistleblower lawsuit. Continue Reading
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23 May 2017
Understanding the Basics of Accountable Care Organizations
Since their inception, accountable care organizations (ACOs) have blazed a path of innovation in the healthcare industry, from delivery to quality of care. Continue Reading
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13 Jan 2017
How Payers Can Improve HEDIS Quality Measure Performance
Population health management, health IT investment, and provider engagement need to be targeted to improve HEDIS quality measure performance. Continue Reading
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07 Oct 2016
How Medicare, Medicaid, and CHIP Guide the Health Payer Industry
Public coverage programs like Medicare, Medicaid, and CHIP are leading the way in value-based care payment models. Continue Reading
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05 Jul 2016
Why HEDIS Quality Measures Matter for Value-Based Care
HEDIS measures are being followed by public health payers that are moving into the value-based care sphere as well. Continue Reading
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30 Dec 2015
The History and Evolution of CHIP and the Medicare Program
When Lyndon B. Johnson took the presidency in 1964, the Medicare program was finally established as a system to provide healthcare coverage to elderly citizens around the nation. Continue Reading